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. 2023 Sep 2;11:84273. doi: 10.52965/001c.84273

Stigmatization as a Barrier to Urologic Care: A Review

Parker Foster 1,, Marie Luebke 2, Abrahim N Razzak 2, Danyon J Anderson 1, Jamal Hasoon 3, Omar Viswanath 3, Alan D Kaye 4, Ivan Urits 5
PMCID: PMC10477007  PMID: 37670795

Abstract

Heavy societal stigma of certain conditions has created an environment where individuals may be hesitant to seek professional care. Urology is a specialized field that focuses on many of these conditions that society has deemed taboo to discuss. In this review, we address barriers that have prevented patients from seeking urologic care in order to better understand and elucidate important concerns within development of the physician-patient relationship. Recognizing these concerns can also assist in public health outreach approaches to motivate patients for seeking urologic care. The scope of this review was limited to three highly prevalent conditions affecting both men and women, including urinary incontinence, erectile dysfunction, and genitourinary syndrome of menopause.

Keywords: Stigma, Urology, Incontinence, Urinary Incontinence, Erectile Dysfunction, Genitourinary Syndrome of Menopause, Barriers to Care

INTRODUCTION

A person’s health is by nature a personal and sensitive topic. This is well illustrated by how society has established norms surrounding the sharing of health information. Individuals often take measures to keep their health status private. It is socially frowned upon to directly question others regarding their health status. Furthermore, numerous state and federal laws have been adopted to protect health information. Indeed, the doctor-patient privilege is widely respected and considered sacrosanct. Only in extenuating circumstances is it allowed to be broken. The personal preference and sensitive nature of the health concern heavily influence how much a condition is shared with others. Generally speaking, conditions characterized by a high prevalence and low perceived risk of stigmatization are broadly shared. These may include conditions such as acne, asthma, or even high blood pressure. Some conditions, however, are met with intense stigma. Intense social stigma has burdened individuals with an intense feeling of needing to keep their condition private. These conditions are generally associated with the urogenital system. Unfortunately, the burden may be so high as to create hesitancy in seeking professional care. Urologists treat many conditions that society has deemed taboo to discuss. Multiple barriers have hindered urologic services from providing effective treatment. In this review, we examine the barriers that have discouraged individuals from seeking care. To focus our efforts, we have limited the scope of this review to examining societal stigma and lack of access to care as barriers to seeking treatment for urinary incontinence, erectile dysfunction, and genitourinary syndrome of menopause; these are three highly prevalent conditions affecting both men and women.

EPIDEMIOLOGY

Urinary Incontinence

Urinary incontinence (UI) is the involuntary leakage of urine, and is characterized by multiple subtypes, including urge, stress, mixed (urge and stress), overflow, and functional.1 The literature reports a broad prevalence of UI, ranging from 12-50% in women and 4-21% in men.2–7 Both men and women experience higher rates of bothersome incontinence with increased BMI and chronic conditions such as heart failure.4 Multiparous women with 4 or more births also have 3-4 times higher prevalence of UI compared to nulliparous women.8 Finally, rates of incontinence correlate with age,4 thus the prevalence of UI is expected to further increase in the coming years due to the United States’ aging population.7,9

Erectile Dysfunction

Erectile dysfunction (ED), also known as impotence, is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance.10 ED has numerous etiologies and subsequently a wide array of treatments. Physiologically, erections are generated by blood flowing into and collecting within the penis. ED can be caused by disruptions in blood flow, such as atherosclerosis, diabetes, and declining testosterone levels.11 Damage to the penile nervous system is also a known precipitant of ED, with etiologies such as multiple sclerosis, Parkinson’s disease, or sequelae of surgery.11 In addition to these chronic conditions, ED has been reported to occur secondary to lower urinary tract symptoms (LUTS).12–14 It is important to note that younger men under 40 generally have different causes of ED than older men, such as subclinical endothelial dysfunction, Peyronie’s Disease, side effects of antidepressants or NSAIDs, and hormonal causes such as hypogonadism.15 Treatment options for ED range from lifestyle modifications, including healthy diet, exercise, and reduction of alcohol consumption or smoking, to medical interventions such as pharmacotherapy, injection therapy, vacuum erectile device, or penile implant surgery.11 In addition to ED, increased age in men also presents with other sexual problems, including lack of interest in sex and inability to reach orgasm.16,17

The prevalence of ED in different populations around the world has been extensively explored. It is generally regarded that ED is more prevalent in older men, which is often supported by the evidence. However, wide discrepancies among all age cohorts have been reported. One major milestone study, the Massachusetts Male Aging Study, reported a prevalence of mild to moderate ED for 52% of men aged 40-70 years.10 A United Kingdom study found similar results, reporting a prevalence of 53%14 in men 45+ years old. Many cross-sectional surveys conducted in North America, Europe, and Australia, though, have reported lower rates for men older than 40, ranging from 21-49%.12,16,18–20 These numbers can be contrasted with ED prevalence studies conducted for the general population, which include men under 40 years old. Here, overall prevalence ranged from 14-26%.21–23 One German survey reported the overall prevalence of ED at 19.2%, however there was a marked age stratification, finding only 2.3% for those aged 30-39, compared to 53.4% in the 70-80 year cohort.22 Another study conducted for men aged 18-39 years of age only saw ED reported in 5% of men in the last 6 months.24

Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM), previously referred to as vulvovaginal atrophy,25 is a term used to describe the genital, sexual, and urinary symptoms associated with menopause. Symptoms include vaginal dryness, dyspareunia, bleeding, discharge, and increased urination.26,27 The decline in estrogen production associated with menopause results in decreased estrogen delivery to the estrogen receptors widely expressed in the female urogenital tract. The absence of estrogen leads to loss of mucosal elasticity, inflamed epithelium, and impaired function.28,29 Changes in the bacterial flora predispose women to recurrent urinary tract infections (UTI).30 Estrogen therapy may be used to reverse the urogenital atrophy which may subsequently improve irritative urinary symptoms.31 Prevalence of GSM has been reported to be present in upwards of 50-80% of post-menopausal women,32–34 with a variable frequency of associated symptoms. Associated symptoms that have been reported include: dryness 27%,35 discharge 18%,35 UI 29%,36 recurrent UTIs 13%.36 Incremental severity of GSM symptoms is associated with significant decreases in quality of life.32

PREVALENCE OF NOT SEEKING CARE

The impact of stigmatization on urogenital conditions manifests before even entering a medical office. For both men and women alike, there is an appreciable prevalence of hesitancy in seeking care.

In women’s health, multiple studies have reported hesitancy. A Swedish epidemiological study of women aged 60-80 years found that only 38.5% of participants with UI had sought treatment.7 An international survey of postmenopausal women from Europe and North America, reported that 71% of interviewees who experienced vaginal discomfort did not discuss it with either their general practitioner or gynecologist.29 Moreover, of those who did receive prescription medication for vaginal discomfort, 25% waited at least a year before discussing their symptoms with a healthcare provider.37 Likewise, a Western European survey involving postmenopausal women reported that 33% of women did not discuss their symptoms of GSM with doctors at all.29 Importantly, this hesitancy is not restricted to older women or those without formal medical training. A study in Western Europe that included all adult women (18+ years old) reported that only 31% had consulted a doctor about their UI symptoms.38 In another study, researchers linked symptom reports to insurance claims in a cohort of nurses with high health literacy; this study demonstrated that only 16% of women with current UI symptoms had an outpatient appointment addressing incontinence.39

Men too display hesitancy in seeking care. In one multinational survey of men aged 50-80 years, researchers found that 90% of the participants reported LUTS, however only 19% sought medical help.12 In another wide-scale survey centered across Western Europe, 52% of men with ED across all ages did not discuss their condition with their physician.24 An Australian phone survey reported that 80% of men with no to mild erectile problems expressed concern about losing erectile function. However, only a third of those with significant ED sought medical treatment. The same study reported an age-related disparity, finding that nearly half of participants aged 40-49 years with an erectile problem had sought medical advice for ED, whereas and only a fifth of those 70+ years of age had sought medical advice.18

Hesitancy in seeking care is a shared problem amongst both men and women. As noted, several medical conditions can precipitate this hesitancy. Interestingly, the hesitancy has afflicted those of all ages and educational status.

ETIOLOGY OF REDUCED CONVERSATIONS

In this section, we will present potential reasons to the social stigma surrounding patients before they reach the urologic clinic office for care. These conversation barriers to seek care for urinary and sexual health symptoms may range from macrosocial viewpoints to individual needs.

Normal Part of Aging

One of the major barriers to seeking care for urinary and sexual health symptoms is a belief that it is a normal part of old age and something one must live with. This barrier is apparent in both men and women.

In an international survey study of 4246 postmenopausal women living in Sweden, Finland, the United Kingdom, the United States, and Canada between the ages of 55-65 conducted by market research institute YouGov Zapera A/S, 28% of women did not tell their partners about their vaginal discomfort because they thought it was “just a natural part of growing older”.40 There also was a report of stoicism regarding female urinary symptoms, in that women felt it was something they must put up with.41 In a phone survey of postmenopausal women aged 45-65 who were not receiving hormone therapy, 51% agreed that they learned to live with vulvar and vaginal symptoms as a normal part of getting older.42 As such, a majority of patients would count the symptoms as a natural process of getting older than seek urologic care.

Men too have been reported to avoid medical attention due to attributing symptoms to a normal part of aging. Interestingly, care seeking for urinary and sexual symptoms is higher amongst men compared to women.43 A study in Central Scotland found that men aged 50 and older associated developing urinary symptoms with aging.44 Furthermore, the study reported that despite urinary symptom interference with daily activities, men believed it was not a sufficient reason alone to consult their general practitioner. Instead, only specific symptoms, such pain, hematuria, and acute retention warranted seeking medical care.44 With regards to ED, a survey of Australian men demonstrated a decreasing level of concern regarding loss of erectile function with escalating age groups. This coincided with older patients being less likely to seek out treatment as compared to the younger aged cohorts.18 Likewise, a population-based study in Minnesota showed that although ED increases with age, older men are less likely to perceive it as a problem compared to younger men,45 a finding that was replicated in other studies.20,21 Notably, a decline in sex drive may be a potential confounder in the findings of reduced care seeking for ED with increased age. However, an international survey of male health issues provides evidence against this. The study found that 47% of men with ED either somewhat or strongly agreed that “when you have this sort of problem, you must learn to accept it” but only 8.5% of men agreed that they were too old for sex.46 This finding suggests that lack of sex drive was not a primary reason for accepting ED as a normal part of aging among older men.

UI, ED, and GSM are indeed associated with aging. Proper patient education on this may assist in patient understanding of onset. However, anticipatory guidance should be provided at annual well-visits that treatments are available. Addressing the belief that the conditions are a normal part of aging and therefore must be accepted is an easy area of intervention that physicians can take to reduce care avoidance.

Perceived Cause of Problem

Another barrier that may impede conversations between physicians and patients is patients’ perception of their problem’s etiology. Patients may believe their symptoms are secondary to something that either does not necessitate medical attention or cannot be fixed. This phenomenon has been most widely documented with ED.

Evidence of this phenomenon has been reported with respect to prostate cancer. Treatment of prostate cancer has a significant adverse effect on erectile function.47 However, one study found that men treated for prostate cancer may be better able to cope with ED than those without prostate cancer.48 It was suggested that men who have received treatment for prostate cancer are able to place their ED into perspective by weighing the importance of treating their cancer. This is in comparison to men suffering from ED without prostate cancer, who may view their ED through the prism of lack of “manliness” as the source of the problem. Effectively, the cancer alleviated the burden of self-blame, as the treatment was likely responsible for the ED.48 A second study exploring ED’s burden in men with treated prostate cancer found a significant association between depressive symptoms and impaired erectile function. The authors noted that a positive treatment prognosis led to decreased worrying and concerns about the cancer, and instead increased distress related to the side effects of treatment.49 Importantly, the latter study did not conclude distress from ED was the result of self-blame. Thus, the presence of prostate cancer does not prevent distress from ED but may allow for protection from self-blame.

Similar results have been demonstrated with other etiologies as well. An Australian telephone survey reported 25% of patients did not seek medical care for their ED due to the belief that the problem was caused by medication side effects or other disorders.18 This finding was echoed by a study of sexually inactive couples, who attributed the inactivity to the male partner’s physical health.19 In both cases, ED was attributed to specific causes, prompting the men to disregard seeking care.

Ultimately, the burden of ED may be mitigated by a perception that ED arose secondary to causes beyond oneself. This, in effect, may provide a protective effect from believing they themselves are at fault for the problem. As a result, patients fail to seek care as they perceive the problem is due to something that cannot be fixed. Further exploration of this topic is warranted to clearly elucidate this conclusion, however.

Degrading

As previously mentioned, ED may result in self-blame. The degrading effects may mount a barrier to the desire to seeking medical help. In essence, patients felt stripped of their masculinity and sexual identity. It was reported that men oftentimes expressed a deep sense of disappointment, describing feelings of frustration, shame, and anxiety. As a result of their ED, they “did not feel like a man”.50 In fact, some reports suggest upwards of 69% of men deny the existence of their ED.10,21 Moreover, even men receiving treatment for ED reported a tendency to avoid sexual situations due to fear that their treatments may fail, causing their ED to be known to others.50

Knowledge of Existing Solutions

Lack of medical awareness may play a major role in care seeking. For instance, patients who do not realize treatments are available may subsequently be less likely to seek treatment. In 1999, it was reported that as many as 76% of patients were concerned that there was no medical treatment for their sexual problems.51 With the high accessibility of internet services and engagement with social media, these rates have likely decreased. However, one study from 2010 showed as many 42% of women did not know there was treatments available for vaginal atrophy.40 An international study of postmenopausal women suggested that most women used over-the-counter treatments for vaginal atrophy, with 46% of respondents noting they were unaware of local estrogen therapy.52 The low awareness of available treatments may be connected to a stigmatization of discussing vaginal conditions.40

Without conversations amongst family, friends, and physicians, patients miss opportunities to learn from others’ experiences. Ultimately, this results in poor awareness of treatment availability and in turn, lack of care seeking.

Embarrassment

Embarrassment was cited amongst the most common reasons as to why patients did not seek care. Across different countries in North America and Europe, between 47-66% of postmenopausal women reported embarrassment as the main reason for not discussing vaginal atrophy with their physicians.40 Another survey conducted in British women aged 55 and older demonstrated that 13% of women who did not seek medical care for painful intercourse or vaginal dryness attributed it to embarrassment. The same study also reported 10% of women said they would be too embarrassed to discuss vaginal itching or soreness, and painful intercourse.41 Notably, this barrier extended beyond the patient-physician relationship. One survey reported that 5.9% of women with vaginal discomfort did not tell their partners due to embarrassment.53

Men too expressed a sense of embarrassment. In an Australian telephone study of men older than 40, approximately 19% of survey respondents cited the inability to talk about their erection problems as their reason for not seeking medical care.18

Another manifestation of embarrassment was in relation to provider characteristics, more specifically, the physician’s gender. Most sources have reported a majority (54-80%) of patients have no preference in the gender of their urologist. However, when gender preference was expressed, the desire was for a gender concordant urologist.54–57 Interestingly, it was also reported that certain situations were associated with a gender preference. For instance, it was found that patients with UI expressed a gender preference,57 as did patients who had a condition they considered embarrassing.56

Societal Views

While many health-related issues are generally perceived to be personal, a societal stigmatization regarding the open dialogue of genitourinary conditions fuels communication barriers. Indeed, a strong belief that certain conditions are inappropriate to discuss has resulted in hesitancy seeking care and poor dissemination of reliable health resources. These issues are well illustrated in women’s health. It was reported that 47% of women agreed that acknowledging they were experiencing menopausal symptoms was a societal taboo.42 The physician’s office has not been immune to the consequences of these feelings. An online survey across 13 countries found that 25% of women felt uncomfortable discussing vagina-related issues with their healthcare providers.58 These findings have been unintentionally created through teaching young girls it is inappropriate to discuss conditions of the vagina. This is best highlighted by the finding that 33% of women admitted to receiving negative vagina-related messages during childhood.58 The consequences of this messaging have also manifested as poor availability of resources on the topic. Less than 40% of women said they had read an informative article about the vagina. Because of this, the International Vagina Dialogue Survey concluded that young women felt societal taboos surrounding the vagina contributed to their ignorance about urogenital and sexual health.58 Patient hesitancy in raising issues has been worsened by physicians also neglecting to address the topic. A European survey reported that only 11-12% of healthcare providers initiated a discussion on GSM with patients, with a finding as low as 5% in the United Kingdom.53 Discussion of the topic generally relied upon the patient initiating the discussion.

Because of the existence of a significant societal stigmatization on certain issues, a strong patient-physician bond is critical toward generating comfort in discussing sensitive topics. Unfortunately, however, it was reported in one European study that only 48% of participants felt a close relationship with their physician.24 An unintended consequence of this impaired relationship may be a fear of dismissal by the physician, perpetuating a possible hesitancy in seeking care. One study found women were hesitant to raise their concerns of vaginal atrophy symptoms as they believed healthcare providers will be dismissive of them.42 A poll in the United States found that 71% of survey respondents felt their doctors would dismiss their concerns about sexual problems if brought up. Despite this, however, 85% of the respondents also said they would still raise the topic even if they felt they would not receive treatment.51 Fortunately, this finding provides hope physicians may still be able to address concerns, though improvements in creating a safe environment to raise the issues is still needed.

Building a trustworthy connection between patients and physicians may assist in decreasing the communication barriers surrounding urogenital conditions. Reducing the societal stigma remains a difficult feat, yet a significant area capable of bettering healthcare.

The Digital Age

In this current digital age, marked by high engagement with social media and an extensive availability of resources (i.e. google), patients may feel more inclined to seek answers privately than to seek professional help. One study examined patients with and without chronic gynecologic pain. The authors found that patients with pain were more likely to use social media and the internet to understand and manage their condition. Additionally, these patients were significantly more likely to trust information on social media, other women with the same condition, informal health resources, and personal sources more than physicians and formal health resources.59 Both males and females were equally likely to engage in social media and internet searches for answers. A report of the most common social media queries for urogenital conditions by gender included low sex drive by females and low sex drive and premature ejaculation by males.60 Women were reported to have a stronger social motive for and experience greater enjoyment in health-related information searches. In contrast, men were more open to engaging in virtual visits with general practitioners.61 These findings provide great insight in how targeting health information may be most effective from a policy perspective. Indeed, as the power of information transmission grows and engagement with social media strengthens, it is imperative that physicians recognize how patients are consuming information. Social stigmas surrounding genitourinary conditions may encourage information seeking from less reliable sources.

CONSEQUENCES

If left untreated, genitourinary conditions are associated with a poor quality of life62 and may significantly impact mental health, including precipitation of depression or anxiety. For example, an inability to control urine can result in frequent bathroom trips and public accidents. This in turn may generate embarrassment with an avoidance of social settings. This was highlighted by a cross-sectional internet survey of men and women in the United States, United Kingdom, and Sweden conducted to estimate the prevalence of LUTS on health-related quality of life, mental health, care utilization, work productivity, and sexual functioning; this study showed a significant correlation between LUTS and worse mental health. Patients with mixed UI (stress and urgency) had the worst rates of anxiety, with 47% of men and 49% of women reporting clinically relevant anxiety. Additionally, 42% of men and 34% of women with mixed UI had clinically relevant depression.43 Indeed, other studies have also noted the toll of UI, including high rates of depression, less work productivity, and lower sexual satisfaction.63 Moreover, UI has a high economic burden64 and severe UI may lead older patients to need placement in a long-term care facility.7

Similarly, the negative personal and social reactions surrounding ED can lead to avoidance of sexual activity.65,66 Unsuccessful sexual episodes may activate negative schemas related to incompetence.67 Anxiety regarding sexual performance can then further perpetuate ED, creating a vicious cycle.68 Avoidance of sexual activities can be correlated with higher rates of depression. Several studies have established a link between ED and depression.49,69–71 While social stigma may hinder conversation around the topic, ED can perpetuate various mental health concerns; given that anxiety and depression surrounding ED can further perpetuate the problem, it is important to recognize and treat mental health quickly as a negative feedback loop may occur. In fact, treatment of ED with PDE5 inhibitors has been shown to improve quality of life scores.24 Unfortunately, reports show that most patients with distressing ED do not seek help.66

CONCLUSION

Genitourinary conditions have been heavily stigmatized by society. The result of this has created an environment where patients are hesitant to seek help. As noted in the review, this hesitancy has manifested in numerous ways, including embarrassment, a belief of having to live with it, and even a lack of knowledge of existing solutions. Importantly, this stigmatization has led patients to seek information privately, which may not be reliable. Oftentimes, patients will not be seen in clinic for treatable genitourinary concerns because of social stigma such as embarrassment or mischaracterizing it as a natural process of aging. It is imperative physicians understand which patients may be hesitant to seek help, how patients are consuming information, and methods that can effectively target patients. Indeed, many solutions have been proposed to address this disparity. The easiest solution physicians can implement is being proactive in generating discussion. For example, men presenting with cardiac or metabolic disease should prompt physicians to screen for ED.24,72 Additionally, identifying patients who are not likely to self-initiate discussion can expedite evaluation and management. This can be accomplished by identifying their tendency to be proactive or reserved.73 Finally, implementing purposeful questioning and screening surveys would potentially benefit all patients.74 Outside of the medical office, public health surveys and approaches calling for normalization of urologic care can also be beneficial. Working with mass media, social media, and the Internet promoting genitourologic care through interviewing and media personalities can allow for enhanced exposure of the topic and reduced stigma to approach such care. Positive exposure on top of more trustworthy sources online may allow for an easier transition for patients to seek office based care. Working to reduce societal stigmatization is the best, yet most difficult solution. However, while trying to change societal perceptions, implementing these simple solutions can provide immediate help to at-risk patients. Normalizing discussions surrounding genitourinary conditions in society can help mitigate and improve the mental health concerns surrounding stigma for urologic care.

References

  1. Diagnosis of urinary incontinence. Khandelwal C., Kistler C. 2013Am Fam Physician. 87(8):543–50. [PubMed] [Google Scholar]
  2. The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the Epidemiology of LUTS (EpiLUTS) study. Coyne Karin S., Sexton Chris C., Thompson Christine L., Milsom Ian, Irwin Debra, Kopp Zoe S., Chapple Christopher R., Kaplan Steven, Tubaro Andrea, Aiyer Lalitha P., Wein Alan J. Aug;2009 BJU Int. 104(3):352–360. doi: 10.1111/j.1464-410x.2009.08427.x. doi: 10.1111/j.1464-410x.2009.08427.x. [DOI] [PubMed] [Google Scholar]
  3. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Irwin Debra E., Milsom Ian, Hunskaar Steinar, Reilly Kate, Kopp Zoe, Herschorn Sender, Coyne Karin, Kelleher Con, Hampel Christian, Artibani Walter, Abrams Paul. Dec;2006 European Urology. 50(6):1306–1315. doi: 10.1016/j.eururo.2006.09.019. doi: 10.1016/j.eururo.2006.09.019. [DOI] [PubMed] [Google Scholar]
  4. Urinary incontinence and chronic conditions in the US population age 50 years and older. Daugirdas Sarunas P., Markossian Talar, Mueller Elizabeth R., Durazo-Arvizu Ramon, Cao Guichan, Kramer Holly. Jan 3;2020 International Urogynecology Journal. 31(5):1013–1020. doi: 10.1007/s00192-019-04137-y. doi: 10.1007/s00192-019-04137-y. [DOI] [PubMed] [Google Scholar]
  5. Innervation distribution pattern, nerve ending structure, and fiber types in pigeon skeletal muscle. Torrella J. R., Fouces V., Palomeque J., Viscor G. Oct;1993 The Anatomical Record. 237(2):178–186. doi: 10.1002/ar.1092370205. doi: 10.1002/ar.1092370205. [DOI] [PubMed] [Google Scholar]
  6. Male urinary incontinence: prevalence, risk factors, and preventive interventions. Shamliyan T. A., Wyman J. F., Ping R., Wilt T. J., Kane R. L. 2009Rev Urol. 11(3):145–65. [PMC free article] [PubMed] [Google Scholar]
  7. An epidemiological study of urinary incontinence and related urogenital symptoms in elderly women. Molander U., Milsom I., Ekelund P., Mellström D. Apr;1990 Maturitas. 12(1):51–60. doi: 10.1016/0378-5122(90)90060-j. doi: 10.1016/0378-5122(90)90060-j. [DOI] [PubMed] [Google Scholar]
  8. Prevalence of urinary incontinence. Thomas T M, Plymat K R, Blannin J, Meade T W. Nov 8;1980 BMJ. 281(6250):1243–1245. doi: 10.1136/bmj.281.6250.1243. doi: 10.1136/bmj.281.6250.1243. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. The future magnitude of urological symptoms in the USA: projections using the Boston Area Community Health survey. Litman Heather J., McKinlay John B. Oct;2007 BJU International. 100(4):820–825. doi: 10.1111/j.1464-410x.2007.07018.x. doi: 10.1111/j.1464-410x.2007.07018.x. [DOI] [PubMed] [Google Scholar]
  10. Erectile dysfunction. Yafi Faysal A., Jenkins Lawrence, Albersen Maarten, Corona Giovanni, Isidori Andrea M., Goldfarb Shari, Maggi Mario, Nelson Christian J., Parish Sharon, Salonia Andrea, Tan Ronny, Mulhall John P., Hellstrom Wayne J. G. Feb 4;2016 Nature Reviews Disease Primers. 2(1):16003. doi: 10.1038/nrdp.2016.3. doi: 10.1038/nrdp.2016.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Erectile Dysfunction. Najari Bobby B., Kashanian James A. Nov 1;2016 JAMA. 316(17):1838. doi: 10.1001/jama.2016.12284. doi: 10.1001/jama.2016.12284. [DOI] [PubMed] [Google Scholar]
  12. Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male (MSAM-7) Rosen Raymond, Altwein Jens, Boyle Peter, Kirby Roger S, Lukacs B, Meuleman Eric, O’Leary Michael P, Puppo Paolo, Robertson Chris, Giuliano Francois. Dec;2003 European Urology. 44(6):637–649. doi: 10.1016/j.eururo.2003.08.015. doi: 10.1016/j.eururo.2003.08.015. [DOI] [PubMed] [Google Scholar]
  13. Sexual dysfunction and lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) Rosen Raymond C., Giuliano Francois, Carson Culley C. Jun;2005 European Urology. 47(6):824–837. doi: 10.1016/j.eururo.2004.12.013. doi: 10.1016/j.eururo.2004.12.013. [DOI] [PubMed] [Google Scholar]
  14. Sexual dysfunction in men with lower urinary tract symptoms. Frankel S.J, Donovan J.L, Peters T.I, Abrams P, Dabhoiwala N.F, Osawa D, Lin A.Tong Long. Aug;1998 Journal of Clinical Epidemiology. 51(8):677–685. doi: 10.1016/s0895-4356(98)00044-4. doi: 10.1016/s0895-4356(98)00044-4. [DOI] [PubMed] [Google Scholar]
  15. Organic causes of erectile dysfunction in men under 40. Ludwig Wesley, Phillips Michael. 2014Urologia Internationalis. 92(1):1–6. doi: 10.1159/000354931. doi: 10.1159/000354931. [DOI] [PubMed] [Google Scholar]
  16. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Nicolosi Alfredo, Laumann Edward O., Glasser Dale B., Moreira Edson D. Jr, Paik Anthony, Gingell Clive. Nov;2004 Urology. 64(5):991–997. doi: 10.1016/j.urology.2004.06.055. doi: 10.1016/j.urology.2004.06.055. [DOI] [PubMed] [Google Scholar]
  17. Sexual problems among women and men aged 40–80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Laumann E O, Nicolosi A, Glasser D B, Paik A, Gingell C, Moreira E, Wang T, for the GSSAB Investigators' Group 2005International Journal of Impotence Research. 17(1):39–57. doi: 10.1038/sj.ijir.3901250. doi: 10.1038/sj.ijir.3901250. [DOI] [PubMed] [Google Scholar]
  18. Men in Australia Telephone Survey (MATeS): a national survey of the reproductive health and concerns of middle-aged and older Australian men. Holden Carol A, McLachlan Robert I, Pitts Marian, Cumming Robert, Wittert Gary, Agius Paul A, Handelsman David J, de Kretser David M. Jul;2005 The Lancet. 366(9481):218–224. doi: 10.1016/s0140-6736(05)66911-5. doi: 10.1016/s0140-6736(05)66911-5. [DOI] [PubMed] [Google Scholar]
  19. A study of sexuality and health among older adults in the United States. Lindau Stacy Tessler, Schumm L. Philip, Laumann Edward O., Levinson Wendy, O'Muircheartaigh Colm A., Waite Linda J. Aug 23;2007 New England Journal of Medicine. 357(8):762–774. doi: 10.1056/nejmoa067423. doi: 10.1056/nejmoa067423. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Age-related changes in general and sexual health in middle-aged and older men: results from the European Male Ageing Study (EMAS) Corona Giovanni, Lee David M., Forti Gianni, O’Connor Daryl B., Maggi Mario, O’Neill Terence W., Pendleton Neil, Bartfai Gyorgy, Boonen Steven, Casanueva Felipe F., Finn Joseph D., Giwercman Aleksander, Han Thang S., Huhtaniemi Ilpo T., Kula Krzysztof, Lean Michael E.J., Punab Margus, Silman Alan J., Vanderschueren Dirk, Wu Frederick C.W. Apr 1;2010 The Journal of Sexual Medicine. 7(4 Part 1):1362–1380. doi: 10.1111/j.1743-6109.2009.01601.x. doi: 10.1111/j.1743-6109.2009.01601.x. [DOI] [PubMed] [Google Scholar]
  21. The prevalence of bother, acceptance, and need for help in men with erectile dysfunction. de Boer B.J., Bots M.L., Nijeholt A. A. B. Lycklama, Verheij T.J.M. May;2005 The Journal of Sexual Medicine. 2(3):445–450. doi: 10.1111/j.1743-6109.2005.20364.x. doi: 10.1111/j.1743-6109.2005.20364.x. [DOI] [PubMed] [Google Scholar]
  22. Epidemiology of erectile dysfunction: results of the ‘Cologne Male Survey’. Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M, Engelmann U. Dec 1;2000 International Journal of Impotence Research. 12(6):305–311. doi: 10.1038/sj.ijir.3900622. doi: 10.1038/sj.ijir.3900622. [DOI] [PubMed] [Google Scholar]
  23. One patient out of four with newly diagnosed erectile dysfunction is a young man--worrisome picture from the everyday clinical practice. Capogrosso Paolo, Colicchia Michele, Ventimiglia Eugenio, Castagna Giulia, Clementi Maria Chiara, Suardi Nazareno, Castiglione Fabio, Briganti Alberto, Cantiello Francesco, Damiano Rocco, Montorsi Francesco, Salonia Andrea. Jul;2013 The Journal of Sexual Medicine. 10(7):1833–1841. doi: 10.1111/jsm.12179. doi: 10.1111/jsm.12179. [DOI] [PubMed] [Google Scholar]
  24. Health-related characteristics and unmet needs of men with erectile dysfunction: a survey in five European countries. Jannini Emmanuele A., Sternbach Nikoletta, Limoncin Erika, Ciocca Giacomo, Gravina Giovanni Luca, Tripodi Francesca, Petruccelli Irene, Keijzer Sylvia, Isherwood Gina, Wiedemann Britta, Simonelli Chiara. Jan;2014 The Journal of Sexual Medicine. 11(1):40–50. doi: 10.1111/jsm.12344. doi: 10.1111/jsm.12344. [DOI] [PubMed] [Google Scholar]
  25. The Recent Review of the Genitourinary Syndrome of Menopause. Kim Hyun-Kyung, Kang So-Yeon, Chung Youn-Jee, Kim Jang-Heub, Kim Mee-Ran. 2015Journal of Menopausal Medicine. 21(2):65. doi: 10.6118/jmm.2015.21.2.65. doi: 10.6118/jmm.2015.21.2.65. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Vaginal and Urinary Symptoms of Menopause. Jin Jill. Apr 4;2017 JAMA. 317(13):1388. doi: 10.1001/jama.2017.0833. doi: 10.1001/jama.2017.0833. [DOI] [PubMed] [Google Scholar]
  27. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Gandhi Jason, Chen Andrew, Dagur Gautam, Suh Yiji, Smith Noel, Cali Brianna, Khan Sardar Ali. Dec;2016 American Journal of Obstetrics and Gynecology. 215(6):704–711. doi: 10.1016/j.ajog.2016.07.045. doi: 10.1016/j.ajog.2016.07.045. [DOI] [PubMed] [Google Scholar]
  28. Atrophic vaginitis. Stika Catherine S. Sep 24;2010 Dermatologic Therapy. 23(5):514–522. doi: 10.1111/j.1529-8019.2010.01354.x. doi: 10.1111/j.1529-8019.2010.01354.x. [DOI] [PubMed] [Google Scholar]
  29. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Nappi R. E., Palacios S. Jan 15;2014 Climacteric. 17(1):3–9. doi: 10.3109/13697137.2013.871696. doi: 10.3109/13697137.2013.871696. [DOI] [PubMed] [Google Scholar]
  30. Postmenopausal vaginal atrophy and atrophic vaginitis. Pandit LOTIKA, Ouslander JOSEPH G. Oct;1997 The American Journal of the Medical Sciences. 314(4):228–231. doi: 10.1097/00000441-199710000-00004. doi: 10.1097/00000441-199710000-00004. [DOI] [PubMed] [Google Scholar]
  31. The role of estrogens in female lower urinary tract dysfunction. Robinson Dudley, Cardozo Linda D. Oct;2003 Urology. 62(4 Suppl 1):45–51. doi: 10.1016/s0090-4295(03)00676-9. doi: 10.1016/s0090-4295(03)00676-9. [DOI] [PubMed] [Google Scholar]
  32. The Association Between Vulvovaginal Atrophy Symptoms and Quality of Life Among Postmenopausal Women in the United States and Western Europe. DiBonaventura Marco, Luo Xuemei, Moffatt Margaret, Bushmakin Andrew G., Kumar Maya, Bobula Joel. Sep;2015 Journal of Women's Health. 24(9):713–722. doi: 10.1089/jwh.2014.5177. doi: 10.1089/jwh.2014.5177. [DOI] [PubMed] [Google Scholar]
  33. Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study. Palma F., Volpe A., Villa P., Cagnacci A. Jan;2016 Maturitas. 83:40–44. doi: 10.1016/j.maturitas.2015.09.001. doi: 10.1016/j.maturitas.2015.09.001. [DOI] [PubMed] [Google Scholar]
  34. Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study. Moral E., Delgado J. L., Carmona F., Caballero B., Guillán C., González P. M., Suárez-Almarza J., Velasco-Ortega S., Nieto C., as the writing group of the GENISSE study Feb 7;2018 Climacteric. 21(2):167–173. doi: 10.1080/13697137.2017.1421921. doi: 10.1080/13697137.2017.1421921. [DOI] [PubMed] [Google Scholar]
  35. Self-reported urogenital symptoms in postmenopausal women: Women’s Health Initiative. Pastore Lisa M., Carter Rachel A., Hulka Barbara S., Wells Ellen. Dec;2004 Maturitas. 49(4):292–303. doi: 10.1016/j.maturitas.2004.06.019. doi: 10.1016/j.maturitas.2004.06.019. [DOI] [PubMed] [Google Scholar]
  36. Prevalence of Genitourinary Symptoms in the Late Menopause. Iosif Constantin S., Bekassy Zoltan. Jan;1984 Acta Obstetricia et Gynecologica Scandinavica. 63(3):257–260. doi: 10.3109/00016348409155509. doi: 10.3109/00016348409155509. [DOI] [PubMed] [Google Scholar]
  37. Distinct neurochemical profiles of spinocerebellar ataxias 1, 2, 6, and cerebellar multiple system atrophy. Öz Gülin, Iltis Isabelle, Hutter Diane, Thomas William, Bushara Khalaf O., Gomez Christopher M. Sep 14;2010 The Cerebellum. 10(2):208–217. doi: 10.1007/s12311-010-0213-6. doi: 10.1007/s12311-010-0213-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Help-seeking behaviour and associated factors among women with urinary incontinence in France, Germany, Spain and the United Kingdom. O’Donnell M., Lose G., Sykes D., Voss S., Hunskaar S. Mar;2005 European Urology. 47(3):385–392. doi: 10.1016/j.eururo.2004.09.014. doi: 10.1016/j.eururo.2004.09.014. [DOI] [PubMed] [Google Scholar]
  39. Outpatient Evaluation and Management Visits for Urinary Incontinence in Older Women. Erekson Elisabeth, Hagan Kaitlin A., Austin Andrea, Carmichael Donald, Minassian Vatche A., Grodstein Francine, Bynum Julie P. W. Aug;2019 Journal of Urology. 202(2):333–338. doi: 10.1097/ju.0000000000000223. doi: 10.1097/ju.0000000000000223. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Women's voices in the menopause: results from an international survey on vaginal atrophy. Nappi Rossella E., Kokot-Kierepa Marta. Nov;2010 Maturitas. 67(3):233–238. doi: 10.1016/j.maturitas.2010.08.001. doi: 10.1016/j.maturitas.2010.08.001. [DOI] [PubMed] [Google Scholar]
  41. Urogenital ageing and its effect on sexual health in older British women. Barlow David H., Cardozo Linda D., Francis Roger M., Griffin Mary, Hart David M., Stephens Elaine, Sturdee David W. Jan;1997 BJOG: An International Journal of Obstetrics and Gynaecology. 104(1):87–91. doi: 10.1111/j.1471-0528.1997.tb10655.x. doi: 10.1111/j.1471-0528.1997.tb10655.x. [DOI] [PubMed] [Google Scholar]
  42. Resistance and barriers to local estrogen therapy in women with atrophic vaginitis. Kingsberg Sheryl A., Krychman Michael L. Jun;2013 The Journal of Sexual Medicine. 10(6):1567–1574. doi: 10.1111/jsm.12120. doi: 10.1111/jsm.12120. [DOI] [PubMed] [Google Scholar]
  43. Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States. Coyne Karin S., Kvasz Marion, Ireland Andrea M., Milsom Ian, Kopp Zoe S., Chapple Chris R. Jan;2012 European Urology. 61(1):88–95. doi: 10.1016/j.eururo.2011.07.049. doi: 10.1016/j.eururo.2011.07.049. [DOI] [PubMed] [Google Scholar]
  44. Perceptions of urinary symptoms and health-care-seeking behaviour amongst men aged 40-79 years. Cunningham-Burley S., Allbutt H., Garraway W. M., Lee A. J., Russell E. B. 1996Br J Gen Pract. 46(407):349–52. [PMC free article] [PubMed] [Google Scholar]
  45. Longitudinal evaluation of sexual function in a male cohort: the Olmsted county study of urinary symptoms and health status among men. Gades Naomi M., Jacobson Debra J., McGree Michaela E., St. Sauver Jennifer L., Lieber Michael M., Nehra Ajay, Girman Cynthia J., Jacobsen Steven J. Sep;2009 The Journal of Sexual Medicine. 6(9):2455–2466. doi: 10.1111/j.1743-6109.2009.01374.x. doi: 10.1111/j.1743-6109.2009.01374.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Attitudes of men with erectile dysfunction: a cross-national survey. Perelman Michael, Shabsigh Ridwan, Seftel Allen, Althof Stanley, Lockhart Dan. May;2005 The Journal of Sexual Medicine. 2(3):397–406. doi: 10.1111/j.1743-6109.2005.20355.x. doi: 10.1111/j.1743-6109.2005.20355.x. [DOI] [PubMed] [Google Scholar]
  47. Erectile function outcome reporting after clinically localized prostate cancer treatment. Burnett Arthur L., Aus Gunnar, Canby-Hagino Edith D., Cookson Michael S., D’Amico Anthony V., Dmochowski Roger R., Eton David T., Forman Jeffrey D., Goldenberg S. Larry, Hernandez Javier, Higano Celestia S., Kraus Stephen, Liebert Monica, Moul Judd W., Tangen Catherine, Thrasher J. Brantley, Thompson Ian, American Urological Association Prostate Cancer Guideline Update Panel Aug;2007 Journal of Urology. 178(2):597–601. doi: 10.1016/j.juro.2007.03.140. doi: 10.1016/j.juro.2007.03.140. [DOI] [PubMed] [Google Scholar]
  48. Is quality of life different for men with erectile dysfunction and prostate cancer compared to men with erectile dysfunction due to other causes? Results from the ExCEED data base. Penson DAVID F., Latini DAVID M., Lubeck DEBORAH P., Wallace KATRINE, Henning JAMES M., Lue TOM. Apr;2003 Journal of Urology. 169(4):1458–1461. doi: 10.1097/01.ju.0000054462.88306.43. doi: 10.1097/01.ju.0000054462.88306.43. [DOI] [PubMed] [Google Scholar]
  49. The association between erectile dysfunction and depressive symptoms in men treated for prostate cancer. Nelson Christian J., Mulhall John P., Roth Andrew J. Feb;2011 The Journal of Sexual Medicine. 8(2):560–566. doi: 10.1111/j.1743-6109.2010.02127.x. doi: 10.1111/j.1743-6109.2010.02127.x. [DOI] [PubMed] [Google Scholar]
  50. Men's experience with penile rehabilitation following radical prostatectomy: a qualitative study with the goal of informing a therapeutic intervention. Nelson Christian J., Lacey Stephanie, Kenowitz Joslyn, Pessin Hayley, Shuk Elyse, Roth Andrew J., Mulhall John P. Feb 24;2015 Psycho-Oncology. 24(12):1646–1654. doi: 10.1002/pon.3771. doi: 10.1002/pon.3771. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Survey says patients expect little physician help on sex. Marwick C. Jun 16;1999 JAMA: The Journal of the American Medical Association. 281(23):2173–2174. doi: 10.1001/jama.281.23.2173. doi: 10.1001/jama.281.23.2173. [DOI] [PubMed] [Google Scholar]
  52. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Nappi R. E., Kokot-Kierepa M. 2012Climacteric. 15(1):36–44. doi: 10.3109/13697137.2011.647840. doi: 10.3109/13697137.2011.647840. [DOI] [PubMed] [Google Scholar]
  53. The CLOSER (CLarifying Vaginal Atrophy's Impact On SEx and Relationships) survey: implications of vaginal discomfort in postmenopausal women and in male partners. Nappi Rossella E., Kingsberg Sheryl, Maamari Ricardo, Simon James. Sep;2013 The Journal of Sexual Medicine. 10(9):2232–2241. doi: 10.1111/jsm.12235. doi: 10.1111/jsm.12235. [DOI] [PubMed] [Google Scholar]
  54. Patients' preference for gender of urologist. Tempest H. V., Vowler S., Simpson A. Apr 12;2005 International Journal of Clinical Practice. 59(5):526–528. doi: 10.1111/j.1368-5031.2005.00465.x. doi: 10.1111/j.1368-5031.2005.00465.x. [DOI] [PubMed] [Google Scholar]
  55. Do Urology Male Patients Prefer Same-Gender Urologist? Amir Hadar, Beri Avi, Yechiely Ravit, Amir Levy Yifat, Shimonov Mordechai, Groutz Asnat. 2018American Journal of Men's Health. 12(5):1379–1383. doi: 10.1177/1557988316650886. doi: 10.1177/1557988316650886. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Patient preference for urologist gender. Wynn Jessica, Johns Putra Lydia. 2021International Journal of Urology. 28(2):170–175. doi: 10.1111/iju.14418. doi: 10.1111/iju.14418. [DOI] [PubMed] [Google Scholar]
  57. Urology is a Sensitive Area: Assessing Patient Preferences for Male or Female Urologists. Ficko Zita, Li Zhongze, Hyams Elias S. Mar;2018 Urology Practice. 5(2):139–142. doi: 10.1016/j.urpr.2017.02.005. doi: 10.1016/j.urpr.2017.02.005. [DOI] [PubMed] [Google Scholar]
  58. Attitudes, perceptions and knowledge about the vagina: the International Vagina Dialogue Survey. Nappi Rossella E., Liekens Goedele, Brandenburg Ulrike. May;2006 Contraception. 73(5):493–500. doi: 10.1016/j.contraception.2005.12.007. doi: 10.1016/j.contraception.2005.12.007. [DOI] [PubMed] [Google Scholar]
  59. Social media utilization, preferences, and patterns of behavior in patients with gynecologic pelvic pain. Piszczek Carolyn C., Foley Christine E., Farag Sara, Northup Megan, Overcarsh Patricia, Wiedrick Jack, Yunker Amanda C., Ecker Amanda M. Apr;2022 American Journal of Obstetrics and Gynecology. 226(4):547.e1–547.e14. doi: 10.1016/j.ajog.2021.10.039. doi: 10.1016/j.ajog.2021.10.039. [DOI] [PubMed] [Google Scholar]
  60. Palm S., Pippen M., Abdelhameed S., Hernandez S., Davila H. PATIENT PERSPECTIVES The Stigma Shroud: Comparison of Female vs Male Social Media Search Involving Pelvic and Sexual Health Conditions. American Urological Association; [Google Scholar]
  61. Gender Differences in Searching for Health Information on the Internet and the Virtual Patient-Physician Relationship in Germany: Exploratory Results on How Men and Women Differ and Why. Bidmon Sonja, Terlutter Ralf. Jun 22;2015 Journal of Medical Internet Research. 17(6):e156. doi: 10.2196/jmir.4127. doi: 10.2196/jmir.4127. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Beyond incontinence: the stigma of other urinary symptoms. Elstad Emily A., Taubenberger Simone P., Botelho Elizabeth M., Tennstedt Sharon L. Aug 23;2010 Journal of Advanced Nursing. 66(11):2460–2470. doi: 10.1111/j.1365-2648.2010.05422.x. doi: 10.1111/j.1365-2648.2010.05422.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. Coyne Karin S., Sexton Chris C., Irwin Debra E., Kopp Zoe S., Kelleher Con J., Milsom Ian. Jun;2008 BJU International. 101(11):1388–1395. doi: 10.1111/j.1464-410x.2008.07601.x. doi: 10.1111/j.1464-410x.2008.07601.x. [DOI] [PubMed] [Google Scholar]
  64. Economic costs of overactive bladder in the United States. Ganz Michael L., Smalarz Amy M., Krupski Tracey L., Anger Jennifer T., Hu Jim C., Wittrup-Jensen Kim U., Pashos Chris L. Mar;2010 Urology. 75(3):526–532.e18. doi: 10.1016/j.urology.2009.06.096. doi: 10.1016/j.urology.2009.06.096. [DOI] [PubMed] [Google Scholar]
  65. Exploring the Role of Sexual Avoidance in Male Sexual Dysfunction. Stephenson Kyle R. 2020The Journal of Sex Research. 57(4):522–533. doi: 10.1080/00224499.2019.1663480. doi: 10.1080/00224499.2019.1663480. [DOI] [PubMed] [Google Scholar]
  66. Sexual Difficulties and Associated Sexual Distress in Flanders (Belgium): A Representative Population-Based Survey Study. Hendrickx Lies, Gijs Luk, Enzlin Paul. Apr;2016 The Journal of Sexual Medicine. 13(4):650–668. doi: 10.1016/j.jsxm.2016.01.014. doi: 10.1016/j.jsxm.2016.01.014. [DOI] [PubMed] [Google Scholar]
  67. “Macho” Beliefs Moderate the Association Between Negative Sexual Episodes and Activation of Incompetence Schemas in Sexual Context, in Gay and Heterosexual Men. Peixoto Maria Manuela, Nobre Pedro. Feb 24;2017 The Journal of Sexual Medicine. 14(4):518–525. doi: 10.1016/j.jsxm.2017.02.002. doi: 10.1016/j.jsxm.2017.02.002. [DOI] [PubMed] [Google Scholar]
  68. Specificity of anhedonic depression and anxious arousal with sexual problems among sexually healthy young adults. Kalmbach David A., Ciesla Jeffrey A., Janata Jeffrey W., Kingsberg Sheryl A. Feb;2012 The Journal of Sexual Medicine. 9(2):505–513. doi: 10.1111/j.1743-6109.2011.02533.x. doi: 10.1111/j.1743-6109.2011.02533.x. [DOI] [PubMed] [Google Scholar]
  69. Increased incidence of depressive symptoms in men with erectile dysfunction. Shabsigh Ridwan, Klein Lonnie T, Seidman Stuart, Kaplan Steven A, Lehrhoff Bernard J, Ritter Joseph S. Nov;1998 Urology. 52(5):848–852. doi: 10.1016/s0090-4295(98)00292-1. doi: 10.1016/s0090-4295(98)00292-1. [DOI] [PubMed] [Google Scholar]
  70. Psychiatric morbidity is frequently undetected in patients with erectile dysfunction. Mallis DIMITRIOS, Moysidis KYRIAKOS, Nakopoulou EVANGELIA, Papaharitou STAMATIS, Hatzimouratidis KONSTANTINOS, Hatzichristou DIMITRIOS. Nov;2005 Journal of Urology. 174(5):1913–1916. doi: 10.1097/01.ju.0000176746.73667.3c. doi: 10.1097/01.ju.0000176746.73667.3c. [DOI] [PubMed] [Google Scholar]
  71. Bidirectional relationship between depression and erectile dysfunction. Shiri Rahman, Koskimäki Juha, Tammela Teuvo L.J., Häkkinen Jukka, Auvinen Anssi, Hakama Matti. Feb;2007 Journal of Urology. 177(2):669–673. doi: 10.1016/j.juro.2006.09.030. doi: 10.1016/j.juro.2006.09.030. [DOI] [PubMed] [Google Scholar]
  72. Erectile Dysfunction. Irwin Gretchen M. Jun;2019 Primary Care: Clinics in Office Practice. 46(2):249–255. doi: 10.1016/j.pop.2019.02.006. doi: 10.1016/j.pop.2019.02.006. [DOI] [PubMed] [Google Scholar]
  73. Characteristics of post-menopausal women with genitourinary syndrome of menopause: Implications for vulvovaginal atrophy diagnosis and treatment selection. Castelo-Branco Camil, Biglia Nicoletta, Nappi Rossella E., Schwenkhagen Anne, Palacios Santiago. Aug;2015 Maturitas. 81(4):462–469. doi: 10.1016/j.maturitas.2015.05.007. doi: 10.1016/j.maturitas.2015.05.007. [DOI] [PubMed] [Google Scholar]
  74. Nocturia in women. Kurtzman Jane T., Bergman Ari M., Weiss Jeffrey P. Jul;2016 Current Opinion in Urology. 26(4):315–320. doi: 10.1097/mou.0000000000000287. doi: 10.1097/mou.0000000000000287. [DOI] [PubMed] [Google Scholar]

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